REGISTRATION FORM- Village of Hinsdale Parks and Recreation
Mail-in or Drop – off: Village of Hinsdale 19 E Chicago Ave, Hinsdale
Fax: 630-789-7016
Online: www. villageofhinsdale. org / pr
Questions 630-789-7090 No phone registration
FAMILY LAST NAME __________________________________________________________________________________________________________ DATE _______________________________ ADDRESS _____________________________________________________________________ CITY ______________________________________________________ ZIP _______________________ PRIMARY PHONE __________________________________________________________________ WORK PHONE _______________________________________________________________ CELL PHONE _____________________________________________________________________ EMERGENCY PHONE _________________________________________________________ EMAIL ADDRESS ____________________________________________________________________________________________________________________________________________________
VERIFICATION OF RESIDENCE Completion of this form & payment confirms that the above information is true and the persons reside at the address listed.
Code Program Name T-Shirt Participant’ s Name Gender D / O / B Fee Size M / F
oM oF oM oF oM oF oM oF oM oF
TOTAL FEES $
PAYMENT INFORMATION( check one): oCash oCheck( payable to: Village of Hinsdale) oCredit Card( Online or In-Person ONLY)
Do you need any special accommodations to participate in a program?______________________________________________________________________________________________________ If yes, please attach an explanation of the needed accommodation. Two week notice is required to ensure accommodations. Do individuals registering for programs have any allergies or dietary restrictions? Describe ______________________________________________________________________________
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WAIVER AND RELEASE
I have read this form carefully, and am aware that by signing this form and registering and participating in, or registering my minor child / ward for and allowing his or her participation in the Programs listed above on this form:( hereinafter referred as the“ program”).
I am WAIVING and RELEASING all claims for myself and my minor child / ward arising out of such registration and participation. In consideration of the Village of Hinsdale( the“ Village”) accepting me and / or my minor child / ward as a participant in the Program, I hereby agree as follows:
ACKNOWLEDGMENT AND ASSUMPTION OF RISK OF INJURY AND LOSS: I have fully informed myself of all of the details of the Program and have received satisfactory answers to all questions I have concerning the Program and the risks inherent in the Program and believe and represent that I and / or my minor child / ward have the necessary abilities, skills and knowledge to participate in the Program. I recognize and acknowledge that the Program involves risks of bodily injury, death and property loss. I hereby agree to, and do, assume the full risk of any injuries, including death, and of any property loss and of all expenses, costs, damages and losses that I, or my minor child / ward on whose behalf I am signing, may sustain as a result of participating in any and all activities connected with or associated with the Program.
WAIVER AND RELEASE OF CLAIMS: I hereby agree to, and do, waive release and relinquish all claims, demands, rights of action, damages, liabilities and controversies of every kind, known and unknown, present and future, that I, or my minor child / ward on whose behalf I am signing, may have against the Village and its officers, agents, servants, employees, insurers, related or affiliated individuals or entities, successors and assign arising out of, connected with, or in any way related to the Program or my minor child / ward’ s participation therein.
INDEMNITY AND DEFENSE: I hereby further agree to indemnify and hold harmless and defend the Village and its officers, agents, servants, employees, insurers, related or affiliated individuals or entities, successors and assigns from any and all claims, lawsuits, demands, damages, liabilities, losses and expenses, including attorney’ s fees and administrative expenses, of every kind, known and unknown present and future, arising out of, connected with, or in any way related to my or my minor child / ward’ s participation in the Program.
EMERGENCY CARE: In the event of an emergency, I authorize the Village to secure, from any licensed hospital, physician and or other medical personnel, any treatment deemed reasonable and necessary for myself and / or my minor child / ward’ s immediate care and agree that I will be responsible for payment for any and all such treatment rendered.
I have read and fully understand the above WAIVER & RELEASE OF ALL CLAIMS and execute it of my own free will and without any reservation whatsoever.
Sign Here:
________________________________________________________________________________________________________________________________________________________________________________________ Signature of parent, guardian, or an adult participant 18 years or older
Date
Participation will be denied if the signature of adult participating / parent / guardian and date are not on this waiver.
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